The diagnostic process is the method by which health professionals select one disease over another, identifying one as the most likely cause of a person’s symptoms. Symptoms that appear early in the course of a disease are often more vague and undifferentiated than those that arise as the disease progresses, making this the most difficult time to make an accurate diagnosis. Reaching an accurate conclusion depends on the timing and the sequence of the symptoms, past medical history and risk factors for certain diseases, and a recent exposure to disease. The physician, in making a diagnosis, also relies on various other clues such as physical signs, nonverbal signals of distress, and the results of selected laboratory and radiological and other imaging tests. From the large number of facts obtained, a list of possible diagnoses can be determined, which are referred to as the differential diagnosis. The physician organizes the list with the most likely diagnosis given first. Additional information is identified, and appropriate tests are selected that will narrow the list or confirm one of the possible diseases.

Historical aspects

Traditionally, diagnosis has been defined as the art of identifying a disease from its signs and symptoms. Formerly, few diagnostic tests were available to assist the physician, who depended on medical history, observation, and examination. In the 20th century there occurred numerous technological advances in medicine, which resulted in the development of a wide variety of diagnostic tests and new techniques to image tissues. These developments significantly improved the ability of doctors to make accurate diagnoses.

In the 5th century bce, at the time of the Greek physician Hippocrates, there arose significant interest in medicine and personal hygiene. The Greeks recognized the salubrious effects of bathing, fresh air, a good diet, and exercise. The ancient Romans also recognized the influence of these factors on health and even made significant advances in supplying and purifying water and in improving sanitation. Today, a balanced diet, clean air and water, and exercise continue to be emphasized as important factors for maintaining health. The ancient Greeks also introduced the notion that illness resulted from an imbalance between the four humours of the body: blood, phlegm, yellow bile, and black bile. They emphasized the value of observation, including bodily signs and excretions. However, the focus was more on predicting the outcome of an illness (i.e., prognosis) and less on its diagnosis. A physician’s reputation depended on accurate prognostic skills, predicting who would recover and who would die or how long an illness would last.

Hippocrates is credited with establishing the ethical basis of the physician’s behaviour, and graduating physicians still recite the Hippocratic oath. His writings document the value of objectively evaluating all aspects of the patient’s symptoms, diet, sleep patterns, and habits. No finding was considered insignificant, and physicians were encouraged to employ all their senses—sight, hearing, smell, taste, and touch—in making a diagnosis. These principles hold just as true today.

Woodcut depicting William Harvey’s theory of the circulation of blood, from his Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus (1628).The Granger Collection, New YorkGalen of Pergamum (129 ce–c. 216) is considered the most influential physician after Hippocrates because of his extensive studies in anatomy and physiology. His voluminous writings rendered him the ultimate authority in these fields until the 16th century. As the first experimental neurologist, he described the cranial nerves and the sympathetic nervous system. He observed the structural differences between arteries and veins. One of his most important demonstrations was that the arteries carry blood, not air, as had been taught for 400 years. However, many of his views contained fallacies, which remained unchallenged for centuries. His description of the heart and its chambers and valves, in which he contended that blood passes from the right to the left ventricle by means of invisible pores in the interventricular septum, delayed the discovery of blood circulation for 14 centuries. The true nature of the circulation of blood was not recognized until the early 17th century, when English physician William Harvey published his findings in Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus (1628; Anatomical Exercise on the Motion of the Heart and Blood in Animals, or simply De Motu Cordis).

One of the greatest advances in diagnosis was the invention of the compound microscope toward the end of the 16th century by the Dutch optician Hans Jansen and his son Zacharias. In the early 17th century, Italian philosopher, astronomer, and mathematician Galileo constructed a microscope and a telescope. The utility of microscopes in the biological sciences and for diagnostic purposes was initially realized in the late 17th century, when Dutch microscopist Antonie van Leeuwenhoek became the first person to see protozoa and bacteria and the first to describe red blood cells (erythrocytes). He also demonstrated the capillary anastomosis (network) between arteries and veins that proved Harvey’s studies of circulation to be correct.

Another advance in diagnostic medicine occurred when the mercury thermometer, invented in 1714 by German physicist Daniel Fahrenheit, came into general use as a clinical tool in the mid-19th century. It was initially 25.4 cm (10 inches) long and took five minutes to register a temperature. The modern clinical thermometer was introduced by English physician Sir Thomas Clifford Allbutt in 1866. The thermometer was popularized by German physician Karl August Wunderlich, who thought, incorrectly, that every disease had its own characteristic fever pattern.

Modern stethoscopes are made of rubber tubing and are binaural, transmitting sounds from a patient’s chest to both ears of the physician.HujiAnother significant medical advance, which greatly improved the ability to diagnose diseases of the chest and heart, was the invention of the stethoscope in 1816 by French physician René-Théophile-Hyacinthe Laënnec. Before this, the lungs and heart were examined by applying the ear to the chest wall. Laënnec’s original stethoscope design consisted of a wooden cylinder and was monoaural, transmitting sound to only one ear. This device allowed Laënnec to diagnose diseases such as tuberculosis at an earlier stage than was previously possible. His wooden stethoscope was replaced at the end of the 19th century by models using rubber tubing; later, binaural stethoscopes, which transmit sound to both ears, came into use. Rubber binaural devices are widely used today.

Another significant diagnostic aid that was developed in the 19th century was the ophthalmoscope, an instrument for inspecting the interior of the eye. The ophthalmoscope was developed in 1850 by German scientist and philosopher Hermann von Helmholtz, who was best known for his knowledge of physics and mathematics. The ophthalmoscope consists of a strong light that can be directed into the eye by a small mirror or prism. The light reflects off the retina and back through a small hole, through which the examiner sees a nonstereoscopic magnified image of the structures at the back of the eye. With this device the retina and its blood vessels can be readily examined. The inner eye can provide information not only about diseases of the eye but also about those pertaining to cardiovascular abnormalities and complications of diabetes mellitus.

Early X-ray photograph by Wilhelm Conrad Röntgen, c. 1896.The Granger Collection, New YorkPerhaps the greatest modern anatomic diagnostic tool is the X-ray, discovered in 1895 by the German physicist Wilhelm Conrad Röntgen. Röntgen found that opaque objects exposed to ionizing radiation could be visualized on a screen coated with fluorescent material, which he demonstrated by producing a photographic image of the bones of the human hand. Since then, knowledge about X-rays, sometimes called roentgen rays, and about various forms of radiation have been applied to the development of computerized axial tomography (CAT), magnetic resonance imaging (MRI), and other imaging techniques that are extremely useful modern diagnostic tools.

William Osler, at the bedside of a patient, while professor of medicine at Johns Hopkins, 1888–1904.Courtesy of the Osler Library, McGill University, MontrealThe training of physicians also has undergone significant change since the time of the ancient Greek physicians. For many centuries, and particularly between the late Middle Ages and the end of the 19th century, physicians were trained through lectures and rarely were taught at the patient’s bedside. This practice was altered by Canadian physician Sir William Osler during his time as professor of medicine at Johns Hopkins University Medical School in Baltimore, Md., U.S. One of the most renowned physicians of the early 20th century, he introduced the practice of instructing students at the bedside of the patient. He emphasized the importance of taking an accurate medical history, providing a thorough examination, and closely observing the patient’s behaviour to gather clues for a diagnosis before resorting to laboratory testing.

Medical history

The medical history of a patient is the most useful and important element in making an accurate diagnosis, much more valuable than either physical examinations or diagnostic tests. The medical interview is the process of gathering data that will lead to an understanding of the disease and the underlying physiological process. To be effective, an interviewer must possess good communication skills and be alert to nonverbal clues as well as to the verbal message. Often, more information is conveyed by nonverbal actions and tone of voice than by words. The objective is to obtain an accurate and comprehensive picture of the patient’s situation, including the nature and timing of symptoms, emotional factors (including types of stress), and past medical conditions that may place the patient at greater risk for certain diseases.

The accuracy and usefulness of the medical interview depend on the physician’s ability to elicit information pertinent to the problem at hand and on the patient’s accurate recall and articulation of the sequence of symptoms. This may be difficult, because meaningful data may be forgotten if the patient is experiencing pain or emotional distress. The skilled interviewer knows when to use silence, open-ended questions, or specific closed-ended questions to explore avenues in which the most useful information may be found. The real reason for the patient’s visit may not be apparent until a rapport has been established and the person feels comfortable describing what is most bothersome. Problems that are emotionally threatening may not be voiced until adequate courage has been summoned—sometimes not until the end of the appointment when the patient’s hand is on the doorknob.

An account of the present illness, which includes the circumstances surrounding the onset of recent health changes and the chronology of subsequent events that have led the patient to seek medical care, is essential to understanding the course of the disease process. Medications are listed in the medical history because they may play a role in the current illness.

The past medical history is an overall view of the patient’s health prior to the present illness. It should include previous hospitalizations, injuries, operations, and any significant illness that may not have required hospitalization. Allergies are included here if not listed separately.

Included in a family history are the age and state of health of each immediate family member as well as the cause of death of any parents, grandparents, and other close relatives. Of particular importance are genetic or environmental diseases that have known risks. If a close relative such as a father died of a heart attack (acute myocardial infarction) before age 60, all his children are at greater risk of suffering an early heart attack. This risk increases if other factors such as hypertension (high blood pressure) or elevated serum cholesterol are present. Similarly, a history of some cancers (e.g., colorectal cancer) increases the risk that offspring will develop that type of cancer. The development of lung cancer in a person provides even greater impetus for close relatives to avoid smoking. Examples of other diseases that may have hereditary roots are diabetes mellitus, schizophrenia and other forms of mental illness, and arthritis. In fact, any disease that arises in two or more members of a family suggests a possible predisposing factor, and the patient should be considered to be at increased risk for this condition.

The occupational history is important because the workplace may be a source of toxins, such as chemicals, asbestos fibres, or cigarette smoke, that place one at higher risk of cancer or other diseases.

The psychosocial history—information on education, lifestyle, marital status, and religious beliefs—may influence future medical decisions, as may the patient’s smoking history, alcohol intake, and use of controlled substances, such as marijuana or cocaine.

The review of body systems allows the physician to identify any other symptoms that have not been noted previously and that may influence the patient’s current state of health or provide subtle clues to the diagnosis. All major body systems are reviewed in an orderly manner, usually from the head down to the extremities. The intent is to uncover any past illnesses or problems that have not been previously identified and that may now or later influence the patient’s health. For example, the patient may describe leg pain while walking, which could be an early indication of blood vessel occlusion and increase the physician’s concern about possible coronary artery disease that otherwise may not have been suspected.

Manual procedures

The physical examination continues the diagnostic process, adding information obtained by inspection, palpation, percussion, and auscultation. When data accumulated from the history and physical examination are complete, a working diagnosis is established, and tests are selected that will help to retain or exclude that diagnosis.

Patients are usually apprehensive and anxious when being examined because they feel exposed, vulnerable, and afraid of discomfort. The physician attempts to allay that anxiety by explaining which examinations are to be performed and the degree of discomfort they will entail. Throughout the examination, concern for the patient’s dignity must be maintained.

Inspection

A wide array of sophisticated instruments are available to assist with examinations, but a well-performed visual inspection can often reveal more information. Osler admonished physicians to closely observe patients before touching them, to cultivate the power of observation, as it is one of the greatest diagnostic tools. Thus, inspection should begin with the patient’s general appearance, state of nutrition, symmetry, and posture. Wasting and hallmarks of poor nutrition may indicate chronic disease; poor grooming or slack posture may suggest depression or low self-esteem. The physician then proceeds to more specific examination of the skin—looking for redness or other signs of infection, hair loss, nail thickening, and moles or other areas of pigmentation—and inquires about any recent changes in skin lesions that could indicate early cancer. Inspection also should encompass, in particular, areas that the patient normally would not be able to see, such as the scalp, the back, and the buttocks.

The nails and the skin are particularly important in making a diagnosis. Examination of the nails can provide important clues about systemic disease. Clubbing of the nails (broadening of the nailbeds, with curved and shiny nails) may indicate congenital heart disease, chronic obstructive pulmonary disease, bronchogenic carcinoma, or another cardiac or pulmonary condition. Pitting of the nails occurs in about 50 percent of patients with psoriasis. The skin should always be inspected for cancer, though it is sometimes difficult to differentiate a benign mole (nevus) from a cancer.

The most dangerous skin cancer, malignant melanoma, occurs in about 1 in 10,000 people and can spread readily throughout the body. A squamous-cell carcinoma also may spread but is slow to do so and can be completely cured by early detection and removal. Basal-cell cancer is the most common form of skin cancer, and, though it is locally invasive, it almost never spreads distantly to other parts of the body. Suspicious lesions are those that have recently enlarged, started to bleed, become darker, or developed an irregular outline. Most skin cancers occur on areas of the body that have been exposed to the sun; they are more common in light-skinned individuals with blond hair and blue eyes who sunburn easily.

The most common premalignant (precancerous) skin lesion is actinic keratosis, a rough, scaling, red or brown papule that appears on sun-exposed areas such as a bald scalp, ears, the forehead, and the back of the hands. These lesions can be easily removed by cryotherapy (therapeutic use of cold), electrodesiccation (dehydration of tissue by electric current), or surgical excision. Some skin lesions, including melanoma, are treated with local excision.

Palpation is the act of feeling the surface of the body with the hands to determine the characteristics of the organs beneath the surface. It can be performed with one hand or two and can be light or deep. Light palpation is used to detect tenderness, muscle spasm, or rigidity of the abdomen. If abdominal pain is present, gentle palpation begins farthest away from the pain to localize the point of maximum tenderness. Acute inflammation in the abdomen, as in acute appendicitis, causes peritoneal irritation, resulting in not only localized tenderness in the right lower abdomen but also a guarding reaction (tightening and rigidity) by the muscles in that area to protect the inflamed organ from the external pressure. Deep palpation of the abdomen is used to determine the size of the liver, spleen, or kidneys and to detect an abnormal mass. An abdominal aortic aneurysm can be detected by palpating a pulsatile mass in the upper abdomen. An acutely tender mass in the right upper abdomen that is more painful on inspiration is probably an inflamed gallbladder. An unexplained nontender abdominal mass could be as nonthreatening as a hard stool or as serious as a tumour.

Palpation also is used to detect and evaluate abnormal lesions in the breast, the prostate gland, the lymph nodes, or the testes. Proper breast examination includes frequent (at least monthly) self-examinations and an annual examination by a physician. Palpation should be methodical and performed over the entire breast; it is done either in concentric circles or outward from the nipple, using a spokes-of-a-wheel approach. Suspicious breast lesions are hard and fixed rather than movable. Skin retraction or breast asymmetry can indicate an underlying, potentially serious lesion. Cancers are usually not tender, and benign lesions are more likely to be round, elastic or firm, movable, and well-defined. Similarly, suspicious prostate lesions are hard irregular nodules within the prostate, whereas benign prostatic hyperplasia (BPH) is a soft symmetrical enlargement of the gland.

Palpation also can detect cardiac enlargement if the point of maximal impulse (PMI) of the heart is farther to the left than normal. Other cardiac abnormalities can be suspected if a thrill is felt from light palpation over the chest wall. A thrill is a vibratory sensation felt on the skin overlying an area of turbulence and indicates a loud heart murmur usually caused by an incompetent heart valve.

Percussion is a diagnostic procedure used to determine the density of a part by tapping the surface with short, sharp blows and evaluating the resulting sounds. In the abdomen it can be used to detect fluid (ascites), a gaseous distention of the intestine as occurs in bowel obstruction, or an enlargement of the liver. It is used most often to evaluate the chest. Percussion produces a resonant note when the area over a healthy lung is struck; a dull sound, however, will emanate if the lung contains fluid, as in pneumonia, or when a region over a solid mass such as the heart is tapped. A lung that is diseased with emphysema contains more air than a healthy lung and produces hyperresonance. A stomach distended with air will produce a high-pitched, hollow tympanic sound.

Auscultation is performed with a stethoscope to evaluate sounds produced by the heart, the lungs, the blood vessels, or the bowels. The lack of bowel sounds indicates a nonfunctioning or paralyzed bowel, and high-pitched “tinkling” bowel sounds suggest bowel obstruction. The “growling” of the stomach is an accentuation of these sounds during periods of bowel hyperactivity.

Bruits are blowing vascular sounds resembling heart murmurs that are perceived over partially occluded blood vessels. When detected over the carotid arteries, a bruit may indicate an increased risk of stroke; when produced by the abdomen, it may indicate partial obstruction of the aorta or other major arteries such as the renal, iliac, or femoral arteries.

Listening to the sound of air passing in and out of the lungs can be useful in detecting an obstruction, as in asthma, or an inflammation, as in bronchitis or pneumonia. Adventitious sounds are those heard in addition to normal breathing sounds and include crackles, wheezes, and rubs. Crackles (also called rales) resemble the sound made by rubbing hair between the fingers next to the ear. They are caused by fluid in the small passageways that adheres to the walls during respiration. Crackles are heard in congestive heart failure and pneumonia. Wheezes, musical sounds heard mostly during expiration, are caused by rapid airflow through a partially obstructed airway, as in asthma or bronchitis. Pleural rubs sound like creaking leather and are caused by pleural surfaces roughened by inflammation moving against each other, which occurs in patients with pneumonia and pulmonary infarction.

Cardiac auscultation is the evaluation of the sounds made by the heart valves—namely, the aortic, the pulmonary, the tricuspid, and the mitral—for murmurs that may be due to turbulent blood flow or vibrations from a heart valve deformity. Murmurs may be physiological (unimportant clinically) or pathological, indicating a problem that needs attention, especially if they reflect obstruction of normal blood flow. Heart murmurs vary according to their timing in the cardiac cycle (i.e., during systole, the period of contraction when blood is pumped from the heart ventricles, or diastole, the period of filling of the right and left ventricles between contraction), location, duration, intensity, pitch, and quality. Intensity is graded on a scale from 1 to 6, with 6 being the loudest. Heart murmurs are described, for example, as “grade 2/6”—the numerator representing the intensity of the murmur, and the denominator indicating the highest grade of the scale being used. However, the intensity of the murmur alone provides little information about the clinical severity of the problem. Depending on its cause, an ejection murmur caused by turbulence across the aortic valve during systole can be either serious or nonthreatening, even though the intensity of the murmur may be the same. Therefore, the pitch and quality of the murmur also are described. Pitch is usually reported as high or low, and quality is described as harsh, soft, blowing, musical, or rumbling. For example, the murmur of mitral stenosis may be described as a grade 3/6, low-pitched, rumbling, presystolic murmur heard best at the apex and having an increased first heart sound at the apex.

Special examinations

Emergency

Of greatest importance in an emergency is the evaluation of systems that are essential to sustaining life—namely, the circulatory, respiratory, and central nervous systems. A person in distress should be checked to determine whether breathing is normal or at least whether there is adequate exchange of air to ensure oxygenation of the blood. If the person is unconscious and normal breathing and circulation have stopped, cardiopulmonary resuscitation, or CPR, is an immediate procedure that can be used to provide temporary artificial respiration and blood circulation. CPR buys time for the trauma victim by supplying life-sustaining oxygen to the brain and other vital organs until fully equipped emergency medical personnel have arrived on the scene.

In an emergency situation, circulation is evaluated by medical personnel to determine whether the person’s cardiac output is adequate to provide oxygenated blood to the tissues. Circulation can be compromised by excessive bleeding or other conditions. A blood pressure greater than 100/60 millimetres of mercury (mm Hg) indicates adequate perfusion. However, when blood pressure falls to extremely low levels, shock occurs. The underlying cause of this precipitous drop characterizes shock; for example, hypovolemic shock is caused by inadequate blood volume, cardiogenic shock is caused by reduced heart function, and neurogenic shock and septic shock are caused by malfunction of the vascular system. This malfunction, which can be caused by severe allergic reaction such as anaphylaxis or by drug overdose, results in severely reduced peripheral vascular tone, in vasodilation, and in pooling of the blood. Signs of shock include a rapid and weak pulse, pale complexion, sweating, and confusion. Organs particularly sensitive to injury if the shock is not corrected are the brain, the heart, the lungs, the kidneys, and the liver.

An unconscious person may not respond to external stimulation, in which case the person would be in a coma, or the patient may exhibit varying levels of unconsciousness, responding only to painful stimuli (deep level of unconsciousness) or when called by name (light level). Pupil size and reactivity to light can provide clues to the status of the nervous system. Bilateral dilated pupils that do not contract when a light is placed on one of them indicate death or severe damage to the nervous system. Small pupils that do react to light are seen in narcotic overdose. If one pupil is larger than the other, a brain lesion or hemorrhage on one side should be suspected.

Examinations to assess the well-being of children begin at birth. The Apgar Score System, named for American physician and anesthesiologist Virginia Apgar, is obtained at one and five minutes after birth and indicates the condition of the newborn. A score of 0 (absent), 1, or 2 is given for each of the five parameters, which are heart rate, respiratory effort, muscle tone, reflex irritability, and colour. Infants scoring between 7 and 10 at one minute will likely do well with no special treatment; those scoring between 4 and 6 may require stimulation or brief respiratory support; those scoring 3 or below will probably need extended resuscitative efforts. Infants who have a score of 7 or above at five minutes will continue to do well. The Apgar score is usually reported as two numbers, from 1 to 10, that are separated by a virgule, the first number being the score at one minute, the second the score at five minutes.

Developmental assessment is measured with growth charts. A child’s length (height) and weight are plotted over time on standard graphs constructed from data gathered from a large number of average-sized children. The average length of a newborn infant is 50 cm (20 inches). The length has increased by 50 percent at 12 months of age and has doubled to 100 cm when the child is 4 years old. The average weight at birth is 3.4 kg (7.5 pounds), which doubles in 4 to 5 months and has tripled when the child is 12 months old. After 2 years of age, height increases by 5 cm (2 inches) and weight increases by 2.3 kg (5 pounds) per year until the growth spurt during adolescence.

Psychosocial development can be measured with the Denver Developmental Screening Test, or Denver Scale. This test, which was developed at the University of Colorado in the United States in the late 1960s, is used today in multiple countries, including Canada and the United Kingdom. The test evaluates motor, language, and social development skills in children up to age six. The test was modified in the 1990s to better detect symptoms of a group of conditions known as pervasive developmental disorders (PDDs), which includes autism, Asperger syndrome, and Rett syndrome. PDDs collectively affect an estimated 30 in every 10,000 children worldwide. Although there are no curative treatments for these disorders, early intervention, such as with speech therapy and behaviour modification therapy, may alleviate some of the social and behavioral symptoms.

The adolescent growth spurt is closely associated with the development of the reproductive system. In developed countries, where the majority of children consume diets fulfilling or exceeding the basic nutrient requirements for physical development, puberty occurs in girls starting, on average, at age 10 or 11 and in boys at age 11. In developing countries, puberty occurs anywhere between ages 12 and 16, depending on dietary factors. In girls the first sign of puberty is the breast bud, followed by breast and pubic hair development. In boys it is growth of the testes with reddening and wrinkling of the scrotum. Pubic hair appears within six months of these first signs of puberty, followed in another six months or so by enlargement of the penis. The full development of the male genitalia may take between 2 and 5 years. In girls the interval from the first indication of puberty to complete maturity may vary from 18 months to 6 years.

Hearing is evaluated early, and a disorder should be suspected if speech is delayed or abnormal. Vision testing is begun in the newborn to detect strabismus (misalignment of the eyes) and other congenital abnormalities. Visual acuity can be evaluated in children when they reach age 2 or 3. Dental appointments should begin when the child is 2 or 3, because the eruption of primary teeth is usually complete by age 2. Permanent teeth begin erupting about age 6 and are all in place by age 12 or 13.

Worldwide, in the 20th and early 21st centuries the number of people who survived to age 65 and over increased significantly. As the body ages, there is a steady loss in organ reserve (ability to function beyond the level normally required, which may be called upon in an emergency), which leads to decreasing functional capacity and increasing vulnerability to disease and disability. Age-related changes include the following:

Muscle mass decreases, as does the mass of the liver, brain, and kidneys.

Cardiac output is reduced; the ability to respond to stress diminishes; and blood flow to the kidneys and other organs decreases.

Pulmonary function decreases because the number of alveoli lessens, expiratory muscles weaken, and there is a reduction in elastic recoil.

Gastrointestinal changes occur, including decreased secretion of stomach acid; decreased intestinal motility, resulting in constipation and dehydration of the stools; slower metabolism of drugs by the liver; increased incidence of gallstones; and loss of teeth, impairing proper chewing and digestion. Diverticulosis, in which the inner lining of the large intestine protrudes out through the surrounding muscular layer, occurs in more than 50 percent of persons by age 80.

Excretory function diminishes because of a decrease in kidney mass and in the number of functioning nephrons.

Neurological changes occur, including a slowing of nerve-conduction velocity, a loss of brain substance, a reduction in the amount of deep sleep and an increase in the number of brief arousals, and a decrease in cerebral blood flow.

Visual acuity, hearing, taste, and smell decline. Vision is much more limited in dim light. The incidence of glaucoma and cataracts increases.

Height decreases because of narrowing of the intervertebral disks and narrowing of the vertebrae, resulting in the loss of 5 cm (2 inches) by age 70.

Dementia (loss of intellectual function) is common among the elderly, and Alzheimer disease is thought to account for more than 60 percent of these cases. Alzheimer disease is characterized by a slowly progressive cognitive decline in the absence of other causes of dementia. In the most common form, typically called late-onset Alzheimer disease, symptoms usually appear around age 60. The risk of the disease increases with age.

Mental examination

Psychological dysfunction and stress-related illness are a significant problem in today’s society. Anxiety and depression represent the two most common mental disorders and are responsible for a high degree of morbidity and mortality.

Depression is one of the most common conditions encountered in medical practice and is twice as prevalent in women as in men. In addition, depression and other mood disorders are more common among older individuals than among younger persons, and the symptoms may be more vague and are likely to manifest physically. Untreated depression can persist for two years or longer. About 60 percent of patients who receive treatment and recover will experience a recurrence of depression within three years. Most episodes of major depression respond well to treatment.

Symptoms of depression may include sleep disturbance (usually early morning awakening), fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to concentrate or make decisions, agitation (anxiety or restlessness) or slowed movements, change in appetite with or without weight loss, and recurrent thoughts of death or suicide. Minor depression, or dysthymia, is the presence of a depressed mood for most of the day. This disorder is diagnosed clinically if symptoms have persisted for two years with no more than two months’ freedom from symptoms. Other symptoms that occur concurrently with this form of depression include disruption in eating habits (poor appetite or overeating), disturbed sleeping pattern (insomnia or hypersomnia), low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and a feeling of hopelessness.

Bipolar disorder is characterized by recurrent episodes of mania and major depression. Most of those who suffer from this condition (60 to 80 percent) initially manifest a manic phase, followed by depression. Manic symptoms consist of feelings of inflated self-esteem or grandiosity, a decreased need for sleep, unusual loquacity, an unconnected flow of ideas, distractibility, or excessive involvement in pleasurable activities that have a high potential for painful consequences, such as buying sprees or sexual indiscretions. Cyclothymia, a milder form of bipolar disorder, is a chronic mood disturbance. For this diagnosis to be made, the patient will have exhibited at least two years of hypomania (moderate mania) and numerous periods of depressed mood that do not meet the criteria for major depression.

With the advent of automated analyzers, an increasing number and variety of tests were made available at greatly reduced cost. A panel of chemical tests for blood and urine have become routine components of the basic medical workup. Blood analysis and urinalysis are used to detect and measure a variety of substances. For example, counts of the different types of blood cells and information about the presence of infectious agents can be obtained by blood analysis. Levels of metabolic products and other chemical substances are often easily detected by urinalysis. There also exist a variety of specific types of analyses, including immunologic blood tests, glucose tolerance tests, genetic tests, and toxicology tests, all of which can provide valuable diagnostic information.

In the case of certain blood and urine tests, a normal laboratory value is one that falls within a range that represents most healthy individuals. However, it is clear that some healthy persons will have values outside that range and some individuals with disease will have values within the normal range. Thus, no sharp line divides normal and abnormal values. Tables of normal reference values must be updated regularly to react to changes in laboratory technique. Many normal values vary dramatically with age and gender.

Worldwide, the standard for reporting laboratory measurements is the International System of Units (SI units). The United States is the only major industrialized country that has not adopted the International System and continues to use customary units of measurement. Most tables provide both units to facilitate communication and understanding.

Imaging instruments and procedures

Endoscopic image of the duodenum.SamirThe formulation of an accurate diagnosis is often facilitated by the use of lighted optical scopes and diagnostic imaging technologies. Procedures such as endoscopy, laparoscopy, and colposcopy make use of generally flexible optical instruments that can be inserted through openings, either natural or surgical in origin, in the body. Many scope instruments are fitted with small video cameras that enable the physician or surgeon to view the tissues being examined on a large monitor. A number of scopes also are designed to enable tissue biopsy, in which a small sample of tissue is collected for histological study, to be performed in conjunction with visual analysis.

One of the most commonly employed diagnostic technologies is X-ray imaging. X-rays are highly effective for obtaining images of bone or other specific tissues. However, their inability to distinguish between different tissues of similar densities limits their applications. Several highly specialized imaging techniques, such as computerized axial tomography (CAT), magnetic resonance imaging (MRI), and positron emission tomography (PET), have largely supplanted traditional X-ray methods. However, when X-rays are used together with special contrast agents, they are capable of imaging select tissues, such as arteries and veins in angiography and the urinary tract in urography.

Pregnant woman having an ultrasound scan.Chad Ehlers—Photographer’s Choice/Getty ImagesOther diagnostic procedures employ electrodes, transducers, or sound waves to produce graphs or traces that provide information about the function and structure of certain organs. For example, in electrocardiography special electrodes connected to a recording instrument are applied to the body; this enables a graphic tracing of the electric current in the heart. Electrocardiography provides detailed information on the condition and performance of the heart. A procedure known as echocardiography relies on the transduction of sound waves into electrical signals to record information about heart structure and function. This technique makes use of the ability of high-frequency sound waves to penetrate through tissues. The use of these sound waves also forms the basis of the diagnostic procedure of ultrasound, which is most commonly used to examine fetuses in utero in order to ascertain size, position, or abnormalities.

As with all medical testing, psychological testing is used as an aid in diagnosis, but no test stands alone. To be of greatest value, each result must be combined with information gathered from the history, clinical evaluation, and other tests. Testing, usually by a trained psychologist, is used to differentiate psychiatric from organic problems, to measure intelligence, to detect or confirm depression or other emotional abnormalities, and to evaluate personality or cognitive functioning. Some of the most commonly used tests are listed below.

The Minnesota Multiphasic Personality Inventory (MMPI) is a questionnaire designed for people over age 18. The 567 true-false statements require a trained psychologist to interpret and to determine the clinical significance of the findings. The test is used to assess psychopathologic status and personality functioning.

The Mini-Mental State Examination (MMSE) is the most widely used screening test for impairment of cognitive function. Developed by American psychiatrist Marshal F. Folstein and colleagues, this brief and easy-to-administer test is used to identify persons with dementia.

Personality functioning and psychopathologic status can be assessed with the 10 inkblot cards of the Rorschach test. The associations that these ambiguous images provoke require expert interpretation, but the results can provide useful information on emotional aberrations.

The Thematic Apperception Test (TAT) uses a series of ambiguous pictures of people in different situations to which the viewer ascribes meaning. The descriptions given are a reflection of the viewer’s anxieties, personal conflicts, and interpersonal relationships.

Information about a person’s concerns and emotional conflicts can be gathered by administering the draw-a-person test and the sentence-completion test.

The Zung Self-Rating Depression Scale, which can be self-administered or given by a trained interviewer, employs 20 items to measure the severity of depression.

Formulating a diagnosis

The process of formulating a diagnosis is called clinical decision making. The clinician uses the information gathered from the medical history and physical and mental examinations to develop a list of possible causes of the disorder, called the differential diagnosis. The clinician then decides what tests to order to help refine the list or identify the specific disease responsible for the patient’s complaints. During this process, some possible diseases will be discarded and new ones added as tests either confirm or deny the possibility that a given disease is present. The list is refined until the physician feels justified in moving forward to treatment. Even after treatment has begun, the list of possible diagnoses may be revised further if the patient does not progress as expected.

The hypotheses are ranked with the most likely disease placed first. However, sometimes a less-likely disease is addressed first because it is more life-threatening and could lead to serious consequences if not treated promptly. Following this course, the possibility of a heart attack would be eliminated first in a patient experiencing chest pain and appendicitis would be the first condition to be addressed in a child with abdominal pain, even though a less-serious disease is more likely.

An algorithm is a sequence of alternate steps that can be taken to solve problems—that is, a decision tree. Starting with a chief complaint or key clue, the physician moves along this decision tree, directed one of two ways by each new piece of information, and eliminates diagnoses. If the wrong path has been taken, the physician returns to a previous branching point and follows the other path. Computers can be used to assist in making the diagnosis; however, they lack the intuition of an experienced physician and the nonverbal diagnostic clues obtained during the interview.

Diagnostic tests rarely establish the presence of a disease without doubt. The greater the sensitivity and the specificity of the test, the more useful it will be. Ordering too many tests poses significant danger, not only because of low cost-effectiveness but also because a falsely abnormal test result requires a further series of tests to prove or disprove its accuracy. This further testing may involve additional discomfort, risk, and cost to the patient, which is especially unfortunate if the tests need not have been ordered in the first place. It is just as important to know when not to order a test as to know which tests to order.

An important feature of clinical decision making is the ongoing relationship between the physician and patient. The knowledge a physician gains in caring for the patient for a long period of time can provide greater insight into the likelihood that a given disease is present. When the symptoms are caused by emotional factors, the familiar personal physician is more likely to accurately diagnose them than is a physician seeing the patient for the first time. Also, a lengthy and trusting association with a physician will often positively influence the patient’s outcome. Thus, sporadic visits to the emergency department of a hospital, where physicians who are unfamiliar with the patient are asked to provide diagnoses and treatment without the benefit of this partnership, are more likely to be inefficient, expensive, and less personally satisfying.

Early in the course of a disease, decisions must be made with fewer clues to the diagnosis than are likely to be available later. One of the most difficult tasks in medicine is to separate, in the early stages of an illness, the serious and life-threatening diseases from the transient and minor ones. Many illnesses will resolve without a diagnosis ever being reached. Nevertheless, an illness may remain undiagnosed for months or years before new symptoms appear and the disease advances to a stage that permits diagnosis. An example is multiple sclerosis, which can present with nothing more than transient blurred vision and may take years before other, more specific symptoms appear.

Patients often have undifferentiated complaints that can represent an uncommon serious disorder or a common but not very serious disorder. For example, a patient may experience fatigue. Depending on the patient’s family history and personal background, the physician may think initially of depression and next of anemia secondary to gastrointestinal bleeding. A variety of less-likely disorders will follow. Anemia is easy to rule out with inexpensive hemoglobin and hematocrit tests. These tests should be ordered even if depression is the correct diagnosis, because anemia may contribute to the weariness and should be treated as well. Depression can be diagnosed with appropriate questioning, and a physical examination may eliminate many other diagnostic possibilities.